Progress in pain management
Pain management is not always given the priority it deserves. An RCN framework aims to equip nurses with the knowledge and skills to assess and support people in pain and to improve pain management practice.
‘Chronic pain affects people’s ability to socialise, and their hygiene, mood and sleep,’ says Felicia Cox, lead nurse specialist and head of pain services at the Royal Brompton and Harefield NHS Foundation Trust in London, and chair of the RCN pain and palliative care forum. ‘Pain is one of the leading causes of re-admission after surgery, contributes to extended hospital stay, and is among the most common reasons to visit a GP.’
Assessing and managing pain are key to nursing care, yet the RCN says nurses often do both poorly. An inadequate response to pain was among the issues highlighted in the Francis inquiry into poor care at Mid Staffordshire NHS Foundation Trust, with hospital staff criticised for not providing patients with the necessary pain relief.
Assessment is paramount. Always ask about pain and act on it when you find it. This cycle of asking and acting is crucial.
Use imaginative ways to find out if someone is in pain, especially if they have dementia, confusion or cannot speak, such as visual or non-verbal aids.
Involve the whole healthcare team. Pain is not just the concern of registered nurses, but of everyone who delivers care.
Source: Karin Cannons
A lack of national standards or competencies for pain management nursing in the UK has been an obstacle to improving practice. But that changed in September, when the RCN published a knowledge and skills framework on pain.
Based on a framework from pain nurses in New Zealand, it looks at understanding and assessing pain; strategies to manage it; service development; and complex pain management.
‘While there is information and some good practice, this draws it all together for the first time,’ says Kate Seers, director of the RCN Research Institute, who has a particular interest in pain management.
‘The framework provides nurses with the core skills to support people in pain, and I think nursing staff across the UK will find it reassuring when they need help,’ she adds.
The framework contains specific elements aimed at both registered and unregistered nursing staff, which Professor Seers says is especially beneficial. ‘By breaking down what nursing staffat all levels need to know, it will help everyone think about what they can do to develop their own skills,’ she says.
‘The framework sets out the complexity and diversity of pain management. It shows how important it is to work with those who have specialist knowledge to improve your own, and emphasises the role of a supervisor or mentor.’
Clinical specialist Nick Allcock of Pain Management Solutions, a consultancy that delivers tailored pain management programmes to NHS patients, agrees that managing pain calls for the active involvement of the whole healthcare team.
‘In some settings, such as care homes, the staffwith the most direct patient contact are often the healthcare assistants,’ he says. ‘They are the ones who recognise when people are in pain, and raise this with registered staff. As there may only be one registered nurse on duty, everyone needs to be pain aware.’
Professor Allcock was involved in developing the framework, and chaired an expert panel discussion. ‘There hasn’t been a publication like this in the UK, which looks across nursing in relation to knowledge and skills about pain,’ he says. ‘It acts as a stimulus to improving education.’
Pain in older people and those who live in care homes is one of his areas of expertise. ‘For older people in particular, managing pain is essential to good quality care,’ he says, adding that while one in five people in the UK have chronic pain, this increases to around 50% of older people in the community and 80% of care home residents.
‘Pain can have a big impact on quality of life. It is such a big issue that it really ought to be a priority, but it is not given the emphasis it needs,’ Professor Allcock says.
He wants to see pain given more prominence in nurse training, including pre-registration courses. His research into nurse training, in collaboration with the British Pain Society, shows that while there are examples of good practice, the current approach is inconsistent.
‘It is patchy, with huge variation in dedicated hours,’ he says. ‘Some courses have separate modules, while in others pain is threaded through, so can get a bit lost.’
A study of European medical schools published in the BMJ last year found that, except in France, just 22% of the schools have a dedicated pain module, and only 9% make it compulsory. In the UK, trainee vets receive more pain education than nursing or medical schools.
‘There are always calls for more and more to be included in the curriculum,’ admits Professor Allcock. ‘But pain is so key’.
For Karin Cannons, nurse consultant in pain management at Frimley Health NHS Foundation Trust in Surrey, everything begins with assessment. ‘Without this initial assessment, nothing can happen to make the patient more comfortable. As nursing staff, we are the early warning system, the first alert.’
While the gold standard of pain assessment is the patient’s own report, there can be barriers to communication, such as dementia, cognitive impairment or a learning disability. ‘Sometimes we might need to use non-verbal ways to gain a picture,’ Ms Cannons says. This could include showing someone images of people’s faces to signal how they might be feeling, even using a blink or nose twitch to acknowledge pain.
Ms Cannons, a co-author of the RCN framework, says it is useful to record when someone is not in pain as this enables staff to track changes if pain develops at a later stage.
She says of the framework: ‘My main hope is it will be a talking point. Nurses are key to every aspect of care because we are at the bedside, observing and accompanying patients.
‘We are their voice, their human monitor. Learning and educating about pain is a constant – it is like painting the Forth Bridge.’